Exercise is the medicine prescribed by physical therapists (PTs). The skilled choice of an exercise mode, such as biking, swimming, treadmill, or circuit training, combined with appropriate dosage determines the effectiveness of exercise medicine. Levinger and Hill articulated that professionals who work with older adults with multimorbidity face the complex problem of dosing exercise at an intensity that promotes adherence while minimizing adverse events. This is certainly true for both exercise professionals with and without clinical backgrounds and licensed health care providers alike. However, DPTs are doctors uniquely trained to provide evidence-based exercise prescription to individuals with complex medical conditions. The PT lens considers the client's unique needs, desires, and comorbidities, and combines that with the best evidence and their own clinical expertise. The skilled clinician then works collaboratively with the client to determine the best modality to increase physical activity. Physical therapists can apply evidence regarding intensity while also considering the client's lumbar stenosis, total knee replacement, and balance problems to create a program that maximizes the benefits of intensity and salience, and promotes adherence and client safety. As an example, let us apply the evidence related to high-intensity exercise and Parkinson's disease (PD).
Recent studies support motor symptom attenuation in PD in individuals who perform high-intensity exercise.1,2 The SPARX trial exercise-tested individuals with PD to determine maximum heart rate, and then randomly assigned individuals to walk on a treadmill at either high intensity (80%-85%) or moderate intensity (60%-65%).1 Individuals were supervised by a research assistant who determined when participants could progress through the stages. While only the high-intensity group showed attenuation of motor symptoms, this group also showed an increased incidence of adverse reactions.1 The Park-in-Shape Trial randomly assigned individuals with PD to a home-based cycling intervention or a stretching intervention.2 Both groups performed their assigned activity 3 times weekly, for 30 minutes. Adherence in both groups was promoted via a motivational application and progress was monitored by a PT or research assistant. Only the stationary bike group, who exercised at a progressive intensity that varied between 50% and 80% of their heart rate reserve, showed attenuation of motor symptoms. These studies demonstrate that intensity matters in individuals in the early stages of PD.
According to Levinger and Hill, both intensity and adherence matter. Randomized controlled trials, like those discussed previously, require researchers to develop strict protocols and exclusion criteria that support the investigation of a specific hypothesis or aim. Research protocols may preclude researchers from adapting their intervention protocols based on individual client needs. For example, a research assistant is not able to move a participant with stenosis-related low back pain from high-intensity treadmill walking to high-intensity biking if the study protocol does not allow it. However, a skilled clinician may review the 2 studies previously discussed and recognize that intensity matters.3 The skilled clinician also understands that while the modality (bike, treadmill, and swimming) does not directly attenuate disease, it does directly impact adherence and potential comorbidities.3 Therefore, the prescription of exercise modality by a skilled clinician indirectly impacts disease attenuation substantially. I highlight this clinical application because it shows the importance of distinguishing between clinicians, researchers, exercise professionals (eg, personal trainers and kinesiologists), and exercise physiologists.
Levinger and Hill did not distinguish the differences between PTs, exercise physiologists, and exercise professionals but rather referred to them collectively as a group. Each of these professions has different skill sets and varied educational backgrounds that offer value to the health care system and the consumer. In an ideal world, PTs would work synergistically with fitness professionals and clinical exercise physiologists within gym or clinical environments. Older adults with complex neurologic conditions such as PD, Alzheimer's disease, or stroke may need more carefully crafted exercise plans and therefore more PT involvement. However, exercise professionals may aid in implementation of exercise plans developed by a PT to meet the individual needs of these older adults living with a chronic neurologic condition. Physical therapists would benefit from better access to results from exercise tests administered by clinical exercise physiologists to dose moderate- to high-intensity exercise, properly and safely. This is especially true in the care of individuals with cardiac comorbidities.
Levinger and Hill's article thoughtfully highlights, not only the necessity, but also the complexities, of exercise prescription in older adults. The topic of complex exercise prescription in older adults accentuates the need for interdisciplinary collaboration between researchers who seek to discover proper dosage of exercise and those professionals who wish to prescribe it. Fitness professionals offer health care providers a partner in promotion of adherence. The clinical exercise physiologist's exercise test results can aid PTs in the prescription of safe and intense exercise.4 If interdisciplinary collaboration is to be effective, each player on the team must understand their role and respect the roles of their teammates. Future research needs to address how researchers, PTs, exercise physiologists, and fitness professionals can work together to address the long-term health needs of the growing older adult population. Further, clinicians must capture their client outcomes longitudinally. Clinical and fitness leadership must collect and disseminate longitudinal outcome data that reflect the benefit of the care provided within their respective facilities. Clinicians, exercise physiologists, and fitness professionals must thoroughly document care provided along with data obtained from appropriate outcome measures. It is through these evidence-based practices that authors like Levinger and Hill will have access to the evidence needed to accurately delineate between professions.
The prevalence of older adults who live with multimorbidity grows as the number of older adults increases.5 Individuals, especially women, who live in underresourced communities and have a lower socioeconomic status are at increased risk to age with multimorbidity or severe multimorbidity.6 As Levinger and Hill discussed, multimorbidity increases the risk of frailty, which then increases risk for falls and mortality. These risks remain greatest in those with the lowest socioeconomic status, a group that tends to engage less in planned exercise, but performs more lifestyle-related physical activity, such as snow shoveling and house cleaning.7 The issues of health disparities and multimorbidity point toward the need for a physical therapy and kinesiology workforce that is as diverse as the population it serves. This workforce must also be equipped as advocates that generate funding to promote planned exercise within the community and in the home environment. As we move forward with skilled exercise promotion, it is imperative that that we do not lose sight of marginalized populations. We know that older adults benefit from exercise; therefore, we have a professional responsibility to ensure that all have equitable access.
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